Healthcare Provider Details

I. General information

NPI: 1376832261
Provider Name (Legal Business Name): CIANNA PENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MIMOSA DR
THOMASVILLE GA
31792-6676
US

IV. Provider business mailing address

100 MIMOSA DR
THOMASVILLE GA
31792-6676
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-8881
  • Fax: 229-584-5964
Mailing address:
  • Phone: 229-226-8881
  • Fax: 229-584-5964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number76648
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: